Effect of menstrual irregularity on academic performance of undergraduate students of Debre Berhan University: A comparative cross sectional study

Background Menstrual period is a critical time in the life of females. For the first few years after menarche, irregular cycle is common due to premature hypothalamic-pituitary ovarian (HPO) axis physiologically. If persistent, it becomes a major problem in student’s life. But few studies conducted on effect of menstrual cycle irregularity on academic performance among university students were descriptive. However assessing the effect of menstrual irregularity on academic performance by using average grade point approach is critically important to magnify its effect. Objective To compare effects of menstrual irregularity on academic performance among undergraduate students of Debre Berhan University, Ethiopia 2020. Methods A comparative cross sectional study was conducted among 404 students in Debre Berhan University, Ethiopia, 2020. A standard tool of menstrual cycle regularity which is prepared by international federation of gynecologist and obstetrics (IFGO) was used to screen students who have menstrual irregularity. Independent sample t- test was done to compare the mean difference of academic performance between the two groups of students. Results The age of study participants ranges between 18 and 26 years with a mean age of 20.69 ± 1.43 years. The mean age at menarche was 14.9 ± 1.67 ranging from 9 to 18 years. Students who had menstrual irregularity had mean average grade point (AGP) of (2.78 ± 0.57) and students who had regular menstruation had mean AGP of (2.97 ± 0.53). Students who had menstrual irregularity had lower mean average grade point by a mean difference of 0.19 (95%CI: 0.09–0.30). Conclusion This study found that students who had menstrual irregularity had significantly lower mean AGP as compared with students who had regular menstruation.

Introduction Regular menstrual cycle (counting from the first day of one menstrual period to the first day of the next cycle) is 21 to 35 days and lasts from 3 to 7 days duration with volume of blood loss 5-80 ml [1]. Menstrual irregularity refer to any kind of changes occurring in regularity of onset, frequency of onset, duration of flow and volume from regular menstrual cycle [2][3][4].
Menstrual period has a notable effect on the academic performance of female students [5]. It influences social life, diet, exercise, amount of sleep, sleep quality, study time, concentration, group activities, preparation and performance on exam and attendance [6,7]. Different studies showed that academic performance of women varies during their menstrual cycle, in a way that the mental status is decreased during and several days before the period [8,9]. In addition, another study conducted in Saudi Arabia revealed that there was an increase rate of absenteeism and loss of concentration in academic work which might have impact on school performances as well as the achievement of their life goals [10]. Study conducted in Mansoura University revealed that more than two third of nursing students had sleeping desire during lectures [11].
The majority of researches regarding effect of menstrual irregularity have been focused on daily activities and descriptive. However assessing the effect of menstrual irregularity on academic performance by using average grade point approach is critically important. Therefore, the aim of this study was to compare the effect of menstrual irregularity on academic performance by using average grade result of the last semester among Debre Berhan university students.

Study design, settings and participants
Institutional based comparative cross sectional study design was conducted in Debre Berhan University from February 11 to March 10 /2020. Debre Berhan is located at 130 Kms from Addis Ababa (capital city of Ethiopia) and at 695 kms from Bahir Dar (the capital city of Amhara Region). There were about 5387 female students during the study period. Undergraduate regular students who were pregnant, who were within one year after delivery and lactating, who had treatment history for menstrual irregularity during the year of study and who were critically ill during data collection period were excluded from the study.

Sample size and sampling procedures
The sample size was calculated using a formula for estimation of double population proportion with the assumption of small to medium effect sizes (Cohen's d = 0.05), 95% confidence interval and a power of 80%. 202 students who have irregular menstrual cycle and 202 students who had regular menstrual cycle were included in the study. The study subjects were selected using simple random sampling (lottery method) technique from the list of the students.

Data collection tools and procedures
A pretested self-administered questioner was used to collect the data. The questionnaire includes socio demographic questions, menestrual cycle pattern related questions, menstrual related symptoms questions, problems faced during menses questions and average grade point of the last semester taken from the students register. The questionnaire was first prepared in English, and translated into Amharic language. A person who was expert in both languages checked the questionnaires' consistency. Two data collectors (graduated public health) and one supervisor (master of public health student) was participated throughout the data collection process.

Measures
Outcome. The investigators want to compare the average grade point of students who have menstrual cycle irregularity with students who have menstrual cycle regularity. In order to assure the comparison similar in academic year only the last one semester average grade point was taken for all students who have regular and irregular menstrual cycle.
Predictors. Whether menstrual cycle is regular or irregular should be determined by using standards of menstrual irregularity definition which was prepared by international federation of gynecology and obstetrics (IFGO) 2018. Therefore, in the present study regular menstrual cycle was defined as if frequency of menses is 24-38 days, duration of bleeding less than or equal to 8 days, cycle to cycle variation over the last one year be less than 10 days and if the individual perception on amount is normal [12]. On the other hand menstrual irregularity refers to anything outside regular menstrual cycle limit.

Data analysis
Epi-data version 3.1 was used for data entry and exported to SPSS version 21 software for analysis. Normality test (by using Kolmogorov-Simonov and Shapiro-wilk test), homogeneity of variance (by using Levene's test) were done. Out layer detection was done by using box and whisker plot. Descriptive statistics such as frequency and percentage were computed for categorical variables. Continuous variables were presented as mean ± standard deviation or median. Independent sample t-test was done to compare the mean difference of academic performance between the two groups of students.

Socio-demographic characteristics
The average age of the students was 20.69 ± 1.43 years old with a range of 18-26. Half of respondents 203 (50.20%) came from rural area and 346 (85.60%) of study participants were orthodox Christian followers (Table 1).

Menstruation and menstrual irregularity
The mean menarcheal age of study subjects was 14.90 ± 1.67 ranging from 9 to 18 years. The average duration of the menstrual cycle lasted between 2-12 days with a mean of 4.84 ± 1.81 days.

Effect of menstrual irregularity on academic performance
The mean average grade point (AGP) of study participants was 2.88 with (SD ±0.57). Furthermore, 45% of students had an average grade point above the mean. Students who had menstrual irregularity had mean AGP of (2.78 ± 0.57) and students who had regular menstruation had mean AGP of (2.97 ± 0.53) ( Table 5).
This study found that students who had menstrual irregularity had significantly lower mean average grade point by a mean difference of 0.19 (95%CI: 0.08-0.30) as compared with students who had regular menstruation (Table 5).

Discussion
The implications of reproductive health on quality of life and other activities are many. This study examines the association between menstrual cycle and academic performance among undergraduate students of Debre Berhan University. In the present study 56.25% of students had no attention in the class, 31.69% were absent from class, 33.48% decrease class activity, 46.43% had low grade achievement and 5.36% were absent from exam during menses. Moreover, students which had menstrual irregularity had significantly lower mean average grade result as compared with students who had regular menstruation. This is in accordance to the Arabian study, which showed that academic performance was affected by menstruation in several ways, mainly study time (76%), concentration (65.8%), participation in group activities (58.1%), examination performance (51.8%) and class attendance (40.8%) [12].
Another study conducted in Mansoura University revealed that 79.5% of nursing students had sleeping desire during lectures, 78.7% experienced restrictions in practical performance, 77.5% had difficulty in concentration and understanding and 75.1%, decreased participation in discussion. In addition study conducted in Kuwait study 75.5% of the participants perceived menstrual discomfort as having negative effects on their participation [13]. A study conducted on the effects of the different phases of the menstrual cycle on physical working capacity showed that the female resting heart and respiratory rates were decease during the menstrual cycle which have adverse effects on physical work output and sport participation [14].
Our study has limitations to consider when interpreting results. First most data on the participant's questioner were self-reported even Average grade result so social desirability bias may be present.

Conclusion
It can be concluded that menstrual irregularity has a major impact on students 'academic performance. This study found that students who had menstrual irregularity had significantly lower mean average grade point as compared with students who had regular menstruation. But this study give insight about the effect of menstrual irregularity on academic performance, further research should be conducted to study the effect of menstrual irregularity on academic performance on university students.
Supporting information S1 Data. Data collected data from Debre Berhan university undergraduate students to assess the effect of menstrual irregularity on academic performance 2020. (SAV) S1 File. Questioner used to assess the effect of menstrual irregularity on academic performance 2020. (DOCX)